Attention-deficit / hyperactivity disorder (ADHD)

How is attention-deficit/hyperactivity disorder diagnosed?

ADHD is the most commonly diagnosed behavior disorder of childhood. A pediatrician, child psychiatrist or a qualified mental health professional usually identifies ADHD in children. A detailed history of the child's behavior from parents and teachers, observations of the child's behavior and psychoeducational testing contribute to making the diagnosis of ADHD. Because ADHD is a group of symptoms, diagnosis often depends on evaluating results from several different types of evaluations, including physical, neuropsychological, educational, and psychosocial/emotional. 

Medications for ADHD

A number of medications are very effective in reducing the "core" characteristics of ADHD, which include the following:

• Inattention
• Impulsivity
• Hyperactivity

Medications that are commonly used to treat ADHD include the following:

• Psychostimulants include two closely related compounds:
  • Methylphenidate (Concerta, Focalin, Metadate, Ritalin, Quillivant)
  • Mixed amphetamine salts: (Adderall, Vyvanse)

• Non-stimulants:
  • Atomoxatine (Strattera)
  • Guanfacine (Intuniv)

Medications have been used to treat childhood ADHD behavior disorders since the 1930s and have been widely studied. Stimulants take effect in the body quickly, work for one to four hours if of the shorter acting type and 8 to 12 hours if of the extended release type, and then leave the body quickly. Extended release preparations of these medications typically work throughout the child's school day and last until dinner time. The common side effects of stimulants, even at therapeutic levels, may include decreased appetite and weight loss, and difficulty initiating sleep at the child's usual bedtime. At higher doses, stimulants can cause headache, stomach ache, jitteriness, or depressed affect. Most side effects of stimulants are mild, decrease with regular use and respond to dose changes. Always discuss potential side effects with your child's physician.

Non-stimulant medications are also effective in treating the "core" symptoms of ADHD, and may be used when a child either does not tolerate or respond well to a stimulant.

It is important to note, however, that recommendations from the American Academy of Pediatrics, (November 2019) regarding treatment of ADHD in children 4-5 years of age, are that evidence-based parent-and/or teacher-administered behavior therapy should be the first line of treatment. This may be followed by prescription of a medication if the child's behavior does not significantly improve with the recommended behavior interventions and there is moderate to severe continuing disturbance in the child's function.

Psychosocial treatments

Parenting children with ADHD may be difficult and can present challenges that create stress within the family. Classes in behavior management skills for parents can help reduce stress for all family members. Training in behavior management skills for parents usually occurs in a group setting which encourages parent-to-parent support. Successful behavior management methods can range from informal approaches such as modifying the frequency and nature of positive and negative feedback to the child by a skilled teacher in the classroom, to more formal methods such as token or point reward systems.

Children with Attention Deficit Hyperactivity Disorder usually benefit from some form of structured management in the home and school setting. Essential components of any behavior management program for children with ADHD should include:

• Targeting specific positive behaviors to be increased through the use of incentives - When you want to change an undesirable behavior, first decide what positive behavior you want to replace it with. Start watching for that positive behavior and when it occurs, praise and reward it.
• The use of precision commands - Commands should be brief sequences of simple statements. Commands should follow these rules: they should be statements, relatively simple, and given in the absence of distraction and only when eye contact is being made. Only one task should be assigned at a time and reinforcement or praise should be given throughout its performance. When giving a command, give immediate feedback for how well your child is doing. Stay and pay attention and comment on your child’s compliance while giving him/her a brief period of time to digest the request.
• Non-contingent quality time with parents - Establish regular one-on-one time with your child during which other children are not involved and you engage in an interactive activity with your child. Allow your child to pick the activity, watch him or her, and join in when appropriate. Do not ask questions or give commands during this time, simply relax and enjoy your child's company. Occasionally provide positive feedback and statements of approval.
• A greater frequency of positives (e.g., praise, rewards) than reprimands - Try to keep a ratio of three positives or rewards for everyone one reprimand or punishment.
• Consistent use of negative consequences that are delivered in an emotionally neutral manner for selected inappropriate behaviors - Decide which problem behaviors to focus on and the consequences for these behaviors. Be consistent in applying the consequence over time, do not give up too soon, respond in the same fashion across environments, and ensure both parents are using the same methods.

Myths and Truths about ADHD

Myth: My child is too young to have ADHD, that doesn't occur until they enter school.
Truth: ADHD symptoms and diagnosis can occur in preschool age children. At times it can be difficult to differentiate normal behaviors from those suggesting ADHD in a young child. It is therefore important to consult a pediatrician and/or pediatric psychologist to have your child formally assessed to determine if an ADHD diagnosis is appropriate.

Myth: My child doesn't have ADHD, he can focus on video games for hours at a time.
Truth: Children with ADHD generally do not experience difficulty focusing on highly engaging, stimulating, and immediately reinforcing stimuli, such as video games. School and other activities however, can be challenging due to the fact that typical classroom lectures and activities are relatively unstimulating in regard to visuals and sounds and require focused attention over long periods of time. Similarly, homework also requires sustained focus along with application of organizational skills, and effort, work demands that are difficult for children with ADHD to sustain.

Myth: Children have ADHD due to poor parenting and lack of discipline.
Truth: There are multiple risk factors for ADHD including genetics and medical causes. ADHD does not result from the type of parenting practices utilized in a home. However, inconsistent limit setting can worsen its expression.

Myth: Providing accommodations, during the school day, to children with ADHD does not help them learn the skills needed to be successful and gives them an unfair advantage.
Truth: Providing children who have ADHD with modifications, such as assignments that are broken into smaller chunks or extended time on tests, actually levels the playing field. Such accommodations allow children with ADHD to display their skills to their full potential and enhance their knowledge while teaching them coping skills they can use into adulthood. In fact, the federal Individuals with Disabilities Act requires public schools to address conditions such as ADHD within the school system.

Myth: Treatment for ADHD will cure my child.
Truth: ADHD is generally a chronic condition that may change over time but usually does not go away. Studies have shown that ADHD can persist into adulthood for as many as 85% of people diagnosed. However, some adults demonstrate enough improvement and develop positive coping skills so that medication is no longer needed.

Myth: ADHD is a condition that only affects boys.
Truth: Girls can have ADHD; however, studies have found that despite need, they are less likely to receive a diagnosis. This phenomenon is due in large part to the fact that girls tend to display less hyperactive symptoms and externalizing disorders in comparison to boys. In contrast, girls are rated as displaying higher levels of inattention and endorse higher levels of internalizing symptoms such as anxiety and depression.

Myth: My child does not have ADHD, he/she is just lazy.
Truth: Children who experience much difficulty staying focused for task completion may act as though they don't care about their work but their struggle stems from a true difficulty in organizing and sustaining their approach to tasks. Children with ADHD want rewards and praise just like any other child, however, their desire for this reinforcement is overridden by true struggles in functioning. ADHD is a true condition not a condition of will.

Myth: Medicine for ADHD will make my child appear drugged and foggy.
Truth: Medicines used to treat ADHD actually do the opposite. They help to control and lessen impulsive behaviors and enhance children's ability to maintain focus on tasks. It may be necessary to try different medications and adjust dosages to ensure that optimal benefits are received.

Myth: The only treatment for ADHD is medication.
Truth: Research has demonstrated that the most effective treatment over the long-term incorporates both medication and parent training. With the inclusion of this additional treatment, family functioning, behavior management skills, children's emotional functioning, and children's self-esteem have all been found to be enhanced.

Adapted from: Barkley, R. (2005). Taking Charge of ADHD, Revised Edition. New York, NY: Guilford Press.

Review resources for ADHD.